Scenario The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430 this morning. She told the ED triage nurse that he had had dysentery for the past 3 days and last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS) were 70/- (systolic blood pressure [BP] 70 mm Hg, diastolic BP inaudible), 110, 20. A 16-gauge IV catheter was inserted, and a lactated Ringer’s (LR) infusion was started.
Malcovich of this patient’s presentation early on in her visit allowed him to investigate the details of her health and psychiatric history. He was also able to check laboratory and test results and have complete access to up-to-the-minute patient care notes. This allowed him to begin contemplating patient management options. St. Theresa’s, unfortunately does not offer inpatient psychiatric services. Therefore, once medically cleared, we have to rely on inpatient psychiatric facilities or group homes like the one Dr. Primrose runs to ensure that these patients remain safe while, in this case, initiating prescriptions to manage medical and psychiatric issues and gathering resources that will be necessary for this patient to regain her independence.
• A 62-year-old diabetic female presents for check-up and dressing change of on left foot. An examination reveals the wound is healing. The nurse applied new dressing and patient will return for a check-up in one week. This patient has a history of wounds on her left foot. The nurse applied new dressing in the wound and medical decision was established.
A series of education training of documentation was implemented to help reduce episodes of Medicare payment denials and self-protection through adequate documentation. Thus, I will discuss the impact of inadequate nursing documentation that leads to malpractice lawsuits. Purpose of Medical Record Documentation Understanding the purpose of medical documentation was the first step in teaching how to prevent inadequate documentations that leads to liability and malpractice lawsuits. Monarch (2007) supports the purpose of Medical Record Documentation as the following: • Substantiating the health condition or illness or presented concern for the patient. • Effective communication among health care staff.
More often a nursing assessment is based on the medical side of the patient rather than the holistic approach. In this assignment I will be discussing the importance of the nursing process, care planning, and looking at how these are used in practice. I will look at the tools used in the nursing process and show an understanding of how effective they are when used correctly. I will achieve this by describing a case study of a patient from my practice area, and discussing two specific areas that affect the patients care. Throughout this assignment I will be using a pseudonym to maintain patient confidentiality in order to conform to ‘The Nursing and Midwifery Code’ (NMC, 2008).
It is also important to know where and how theories can best apply to current nursing practice. Compare and Analyze a Common Core Concept A common core concept among Virginia Henderson’s need theory and Dorothea Orem’s self-care deficit nursing theory is nursing. Both theorists use the nursing concept in their theory to define the role of nursing. Henderson defines nursing as the unique function of a nurse to help a person sick or well in the performance of activities contributing to health or its recovery that the person would perform unaided if he or she had the necessary strength, will, or knowledge. Nursing can also consist of assisting an individual to a peaceful death.
Risk Assessment: Cor Pulmonale NR 282 Pathophysiology II Spring B – 2013 Cor Pulmonale Introduction My patient is a 42 year old Hispanic female with a past medical history of pneumonia and hypertension. She is a single mother with one child (son) and is employed as a cleaner in a general hospital. She denies smoking but drinks alcohol occasionally. She denies using recreational drugs. The patient presented to her physician’s office with shortness of breath, chest pain, excessive coughing, and excessive fatigue and states that, “she has fainted on occasion before”.
I was in a double room and my roommate, Marie, a heavy girl, had jumped off the roof of her house and shattered her knee. She was there almost as long as I was and I later saw her at physical therapy. She never walked the same again and experienced several complications while in the hospital. What seemed like a simple fracture turned into a nightmare for her, and what seemed like a hopeless situation for me turned out alright. I couldn’t help but wonder why I was so lucky.
She then began to cut causing harm to herself by cutting herself. In February of 2001, Andrea Yates father died and at that point Yates stopped talking, drinking liquids, nursing the baby, and began pulling out her hair. Andrea Yates was admitted into a hospital for the third time. Andrea Yates was started back on the antipsychotic drug therapy. More than one of the doctors that Andrea Yates has seen, sees a sick person which they view her.
As a health care professional trained in different approach, I assessed my client based on the theory and learning experience that I have had. The client was been diagnosed with dementia, limited mobility, and inadequate verbal communication. I undertook a full assessment to a client with a sacral pressure sore. Assessment using observation was been completed to the sacral area, and graded the level of pressure ulcer using the Braden scale. The nurse mentor was been informed about the type of dressing and intervention that should be provided to the client, along with the explanation with the rationale to the procedure that I have decided to use.